Pharmacological aspects of the combined use of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) and gamma-hydroxybutyric acid (GHB): a review of the literature

MDMA-Based Psychotherapy in Treatment-Resistant Post-Traumatic Stress Disorder (PTSD): A Brief Narrative Overview of Current Evidence

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that causes significant dysfunction in individuals. Currently, there are many approved pharmacotherapy and psychotherapy treatment options for PTSD, but unfortunately, half of the patients do not respond to traditional therapies. In this article, we review clinical trials and research on 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy in PTSD patients, its pharmacokinetics, and current treatment guidelines for PTSD. Our findings are based on the results of the efficacy of MDMA-assisted psychotherapy from six phase II randomized controlled trials. MDMA-assisted psychotherapy for PTSD has received the "breakthrough therapy" designation from the FDA. MDMA can reduce PTSD symptoms even in treatment-resistant cases by increasing certain neurohormones, i.e., dopamine, serotonin, norepinephrine, and oxytocin. It also modulates activities in the brain regions involved in fear and anxiety. Future research is needed to show whether the advantages outweigh the disadvantages and whether its use can be integrated into available treatment options for PTSD.

Characteristics of analytically confirmed gamma-hydroxybutyrate (GHB) positive patients in the emergency department: presentation, poly-drug use, disposition and impact on intensive care resource utilisation

BACKGROUND

Gamma-hydroxybutyrate is a potent central nervous system depressant with a narrow recreational dose window and analytical detection time. We describe data relating to intoxicated patients presenting to emergency departments across metropolitan Adelaide who tested positive for gamma-hydroxybutyrate. This work was part of the Emergency Department Admission Blood Psychoactive Testing study.

METHODS

Over a 15-month period, patients presenting to four metropolitan emergency departments with symptoms of drug intoxication were enrolled in the study. The methodology involved the collection of demographic and clinical data and a de-identified blood sample which underwent comprehensive toxicological analysis. Gamma-hydroxybutyrate was determined using an acid-catalysed cyclisation followed by liquid-liquid extraction and gas chromatography-mass spectrometry. Data relating to samples positive for gamma-hydroxybutyrate were examined.

RESULTS AND DISCUSSION

A total of 1120 patients were enrolled between March 2019 and May 2020, 309 of whom were positive for gamma-hydroxybutyrate (27.6%). Of these, 256 (83%) were also positive for metamfetamine (methamphetamine). The most common clinical observation in gamma-hydroxybutyrate-positive patients was central nervous system depression (89%). There was a significant relationship between gamma-hydroxybutyrate status and sex; although males outnumbered females in absolute terms, a higher proportion of females (32%) tested positive for gamma-hydroxybutyrate than males (25%, P = 0.0155). Blood gamma-hydroxybutyrate concentrations ranged from 10 to 651 mg/L (0.096-6.2 mmol/L) and increasing gamma-hydroxybutyrate concentration correlated with severe toxicity. The presence of gamma-hydroxybutyrate had a significant impact on the patient discharge destination: the majority (69.2%) of gamma-hydroxybutyrate-positive patients were managed and discharged from the emergency department or their attached short stay wards. A significantly higher proportion of gamma-hydroxybutyrate-positive patients were admitted to the intensive care unit (28.2%) compared with gamma-hydroxybutyrate-negative patients (12.7%, chi-squared = 36.85, P <0 .001). Gamma-hydroxybutyrate positive cases accounted for 45.8% of all study-related intensive care unit admissions.

CONCLUSIONS

Gamma-hydroxybutyrate is commonly detected in illicit drug-related emergency department presentations and is detected disproportionately in the patient cohort who require intensive care unit level care.

Causes and Consequences of Drug Abuse: A Comparison Between Synthetic Drug and Heroin Users in Urban China

This article examined the differences in causes and health consequences between synthetic drug and heroin abuse in urban China. Two-group comparisons were conducted to quantify differences in individual characteristics, causes of drug use, and HIV/STI risky sexual behavior between synthetic drug and heroin users; logistic regressions were employed to assess the net effect of synthetic drug use on risky sexual behavior. Results revealed that causes of synthetic drug use differed from those of heroin use; a combination of the knowledge gap concerning the harmful impact of synthetic drugs and the lesser punishment for their use appeared a main reason behind the shift from heroin to synthetic drugs; and synthetic drug use was a significant and powerful risk factor for HIV/STI risky sexual behavior. Educational and behavioral interventions are urgently needed to prevent the initiation of synthetic drug use among users to reduce their HIV/STI risky sexual behavior.

The behavioural profile of gamma-hydroxybutyrate, gamma-butyrolactone and 1,4-butanediol in humans

Gamma-hydroxybutyrate (GHB) is a putative neurotransmitter, a drug of abuse, and a medical treatment for narcolepsy and other neuropsychiatric disorders. Its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are endogenously converted to GHB and thereby exert their psychobehavioural effects. In humans, GHB has a wide spectrum of properties ranging from stimulation and euphoria in lower doses, to sedation, deep sleep, and coma after ingestion of high doses. However, behavioural studies in healthy volunteers remain scarce and are usually limited to psychomotor performance testing. Most available data arise from either qualitative studies with illicit users or clinical trials examining therapeutic properties of GHB (then usually termed sodium oxybate). Here, we present an overview of the behavioural effects of GHB, GBL, and 1,4-BD in these three populations. GHB and its precursors strongly influence behaviours related to core human autonomic functions such as control of food intake, sexual behaviour, and sleep-wake regulation. These effects are instrumentalised by illicit users and clinically utilised in neuropsychiatric disorders such as narcolepsy, fibromyalgia, and binge-eating syndrome. Considering the industry withdrawal from psychopharmacology development, repurposing of drugs according to their behavioural and clinical profiles has gained increasing relevance. As such, GHB seems to be an attractive candidate as an experimental therapeutic in depression.

Gamma-hydroxybutyrate enhances mood and prosocial behavior without affecting plasma oxytocin and testosterone

Gamma-hydroxybutyrate (GHB) is a GHB-/GABAB-receptor agonist. Reports from GHB abusers indicate euphoric, prosocial, and empathogenic effects of the drug. We measured the effects of GHB on mood, prosocial behavior, social and non-social cognition and assessed potential underlying neuroendocrine mechanisms. GHB (20mg/kg) was tested in 16 healthy males, using a randomized, placebo-controlled, cross-over design. Subjective effects on mood were assessed by visual-analogue-scales and the GHB-Specific-Questionnaire. Prosocial behavior was examined by the Charity Donation Task, the Social Value Orientation test, and the Reciprocity Task. Reaction time, memory, empathy, and theory-of-mind were also tested. Blood plasma levels of GHB, oxytocin, testosterone, progesterone, dehydroepiandrosterone (DHEA), cortisol, aldosterone, and adrenocorticotropic-hormone (ACTH) were determined. GHB showed stimulating and sedating effects, and elicited euphoria, disinhibition, and enhanced vitality. In participants with low prosociality, the drug increased donations and prosocial money distributions. In contrast, social cognitive abilities such as emotion recognition, empathy, and theory-of-mind, and basal cognitive functions were not affected. GHB increased plasma progesterone, while oxytocin and testosterone, cortisol, aldosterone, DHEA, and ACTH levels remained unaffected. GHB has mood-enhancing and prosocial effects without affecting social hormones such as oxytocin and testosterone. These data suggest a potential involvement of GHB-/GABAB-receptors and progesterone in mood and prosocial behavior.

Concurrent and simultaneous polydrug use among young Swiss males: use patterns and associations of number of substances used with health issues

BACKGROUND

Simultaneous polydrug use (SPU) may represent a greater incremental risk factor for human health than concurrent polydrug use (CPU). However, few studies have examined these patterns of use in relation to health issues, particularly with regard to the number of drugs used.

METHODS

In the present study, we have analyzed data from a representative sample of 5734 young Swiss males from the Cohort Study on Substance Use Risk Factors. Exposure to drugs (i.e., alcohol, tobacco, cannabis, and 15 other illicit drugs), as well as mental, social and physical factors, were studied through regression analysis.

RESULTS

We found that individuals engaging in CPU and SPU followed the known stages of drug use, involving initial experiences with licit drugs (e.g., alcohol and tobacco), followed by use of cannabis and then other illicit drugs. In this regard, two classes of illicit drugs were identified, including first uppers, hallucinogens and sniffed drugs; and then "harder" drugs (ketamine, heroin, and crystal meth), which were only consumed by polydrug users who were already taking numerous drugs. Moreover, we observed an association between the number of drugs used simultaneously and social issues (i.e., social consequences and aggressiveness). In fact, the more often the participants simultaneously used substances, the more likely they were to experience social problems. In contrast, we did not find any relationship between SPU and depression, anxiety, health consequences, or health.

CONCLUSIONS

We identified some associations with SPU that were independent of CPU. Moreover, we found that the number of concurrently used drugs can be a strong factor associated with mental and physical health, although their simultaneous use may not significantly contribute to this association. Finally, the negative effects related to the use of one substance might be counteracted by the use of an additional substance.

Effect of 3,4-methylenedioxymethamphetamine on the toxicokinetics and sedative effects of the drug of abuse, γ-hydroxybutyric acid

γ-Hydroxybutyric acid (GHB) is widely abused in combination with other club drugs such as 3,4-methylenedioxymethamphetamine (MDMA). The objectives of this study were to characterize the effects of MDMA on GHB toxicokinetics/toxicodynamics (TK/TD) and evaluate the use of monocarboxylate transporter (MCT) inhibition as a potential treatment strategy for GHB overdose when GHB is abused with MDMA. Rats were administered GHB 400 mg/kg i.v. alone or with MDMA (5 mg/kg i.v). Effects of MDMA and of the MCT inhibitor, l-lactate, on GHB TK and sedative effects were evaluated. The results of this study demonstrated no significant effect of MDMA on GHB TK or TD. GHB plasma concentrations were unchanged, and GHB concentration-effect relationships, based on plasma and brain concentrations and the return-to-righting reflex (RRR), were similar in the presence and absence of MDMA. l-Lactate administration resulted in a significant decrease in the sedative effect (RRR) of GHB when it was coadministered with MDMA. Our results indicate that MDMA does not affect the TK/TD of GHB at the doses used in this study, and MCT inhibition using l-lactate, an effective overdose treatment strategy for GHB alone, is also effective for GHB overdose when GHB is coingested with MDMA.

The acute effects of MDMA and ethanol administration on electrophysiological correlates of performance monitoring in healthy volunteers

RATIONALE

Knowing how commonly used drugs affect performance monitoring is of great importance, because drug use is often associated with compromised behavioral control. Two of the most commonly used recreational drugs in the western world, 3,4-methylenedioxymethamphetamine (MDMA or "ecstasy") and ethanol (alcohol), are also often used in combination. The error-related negativity (ERN), correct-related negativity (CRN), and N2 are electrophysiological indices of performance monitoring.

OBJECTIVES

The present study aimed to investigate how ethanol, MDMA, and their co-administration affect performance monitoring as indexed by the electrophysiological correlates.

METHODS

Behavioral and EEG data were obtained from 14 healthy volunteers during execution of a speeded choice-reaction-time task after administration of ethanol, MDMA, and combined ethanol and MDMA, in a double-blind, placebo-controlled, randomized crossover design.

RESULTS

Ethanol significantly reduced ERN amplitudes, while administration of MDMA did not affect the ERN. Co-administration of MDMA and ethanol did not further impair nor ameliorate the effect of ethanol alone. No drug effects on CRN nor N2 were observed.

DISCUSSION

A decreased ERN following ethanol administration is in line with previous work and offers further support for the impairing effects of alcohol intoxication on performance monitoring. This impairment may underlie maladaptive behavior in people who are under influence. Moreover, these data demonstrate for the first time that MDMA does not affect performance monitoring nor does it interact with ethanol in this process. These findings corroborate the notion that MDMA leaves central executive functions relatively unaffected.

Toxicity of amphetamines: an update

Amphetamines represent a class of psychotropic compounds, widely abused for their stimulant, euphoric, anorectic, and, in some cases, emphathogenic, entactogenic, and hallucinogenic properties. These compounds derive from the β-phenylethylamine core structure and are kinetically and dynamically characterized by easily crossing the blood-brain barrier, to resist brain biotransformation and to release monoamine neurotransmitters from nerve endings. Although amphetamines are widely acknowledged as synthetic drugs, of which amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) are well-known examples, humans have used natural amphetamines for several millenniums, through the consumption of amphetamines produced in plants, namely cathinone (khat), obtained from the plant Catha edulis and ephedrine, obtained from various plants in the genus Ephedra. More recently, a wave of new amphetamines has emerged in the market, mainly constituted of cathinone derivatives, including mephedrone, methylone, methedrone, and buthylone, among others. Although intoxications by amphetamines continue to be common causes of emergency department and hospital admissions, it is frequent to find the sophism that amphetamine derivatives, namely those appearing more recently, are relatively safe. However, human intoxications by these drugs are increasingly being reported, with similar patterns compared to those previously seen with classical amphetamines. That is not surprising, considering the similar structures and mechanisms of action among the different amphetamines, conferring similar toxicokinetic and toxicological profiles to these compounds. The aim of the present review is to give an insight into the pharmacokinetics, general mechanisms of biological and toxicological actions, and the main target organs for the toxicity of amphetamines. Although there is still scarce knowledge from novel amphetamines to draw mechanistic insights, the long-studied classical amphetamines-amphetamine itself, as well as methamphetamine and MDMA, provide plenty of data that may be useful to predict toxicological outcome to improvident abusers and are for that reason the main focus of this review.

Residual social, memory and oxytocin-related changes in rats following repeated exposure to γ-hydroxybutyrate (GHB), 3,4-methylenedioxymethamphetamine (MDMA) or their combination

RATIONALE

There has been little investigation of the possible lasting adverse effects of γ-hydroxybutyrate (GHB).

OBJECTIVES

This study aims to study whether GHB produces residual adverse effects on memory and social behaviour in rats and lasting changes in brain monoamines and oxytocin-related gene expression.

METHODS

Rats received daily intraperitoneal injections of GHB (500 mg/kg), methylenedioxymethamphetamine (MDMA; 5 mg/kg) or their combination (GHB/MDMA) over ten consecutive days. Locomotor activity and body weight were assessed during the dosing period and withdrawal-related anxiety was assessed 24 h after drug cessation. After a washout of 4 weeks, rats were tested on the emergence, social interaction, and object recognition tasks over a 2-week period. Monoamine levels in cortex and striatum, and hypothalamic oxytocin and oxytocin receptor mRNA, were then assessed.

RESULTS

MDMA and GHB/MDMA caused modest sensitization of locomotor activity over time, while sedative effects of GHB diminished with repeated exposure. GHB-treated rats showed reduced social interaction 24 h after the final dose, indicating GHB withdrawal-induced anxiety. All drug-treated groups displayed residual deficits in social interaction and object recognition. No changes in monoamine levels were detected 8 weeks post-drug. However, MDMA pre-exposure increased hypothalamic oxytocin mRNA while GHB pre-exposure upregulated oxytocin receptor mRNA. GHB/MDMA pre-exposure caused intermediate changes in both of these measures.

CONCLUSIONS

GHB treatment caused residual impairments in memory and social behaviour and increases in anxiety, paralleling the lasting adverse effects of MDMA. Both drugs caused lasting neuroadaptations in brain oxytocin systems and this may be related to the long-term social interaction deficiencies caused by both drugs.

Club drug use in Hispanic college students

Club drug use and correlates were examined among 251 Hispanic college students on the Texas-México border. Participants completed questionnaires on substance use, club drug attitudes and beliefs, sexual risk-taking behaviors, depressive symptoms, and acculturation. One-quarter of participants reported club drug use. Regression analyses demonstrated that frequency and history of lifetime use were consistently associated with more permissive drug attitudes and other substance use but not sexual risk-taking, depression symptoms, or acculturation. Acculturation was negatively associated with frequency of club drug use, yet positively associated with use of other illicit substances. Avenues for future studies are suggested.

Sedative and hypothermic effects of gamma-hydroxybutyrate (GHB) in rats alone and in combination with other drugs: assessment using biotelemetry

The recreational drug gamma-hydroxybutyrate (GHB) has euphoric effects and can induce sedation and body temperature changes. GHB is frequently combined with other recreational drugs although these interactions are not well characterised. The present study used biotelemetry to provide a fine-grained analysis of the effects of GHB on body temperature and locomotor activity in freely moving rats, and investigated interactions between GHB and 3,4-methylenedioxymethamphetamine (MDMA), methamphetamine (METH) and various antagonist drugs. GHB (1000mg/kg) caused profound sedation for more than 2h and a complex triphasic effect on body temperature: an initial hypothermia (5-40min), followed by hyperthermia (40-140min), followed again by hypothermia (140-360min). A lower GHB dose (500mg/kg) also caused sedation but only a hypothermic effect that lasted up to 6h. The dopamine D(1) receptor antagonist SCH 23390 (1mg/kg), the opioid antagonist naltrexone (1mg/kg), the benzodiazepine antagonist flumazenil (10mg/kg), and the 5-HT(2A/2C) receptor antagonist ritanserin (1mg/kg) did not prevent the overall sedative or body temperature effects of GHB (1000mg/kg). However the GABA(B) antagonist SCH 50911 (50mg/kg) prevented the hyperthermia induced by GHB (1000mg/kg). Repeated daily administration of GHB (1000mg/kg) produced tolerance to the sedative and hyperthermic effects of the drug and cross-tolerance to the sedative effects of the GABA(B) receptor agonist baclofen (10mg/kg). A high ambient temperature of 28 degrees C prevented the hypothermia obtained with GHB (500mg/kg) at 20 degrees C, while GHB (500mg/kg) reduced the hyperthermia and hyperactivity produced by co-administered doses of MDMA (5mg/kg) or METH (1mg/kg) at 28 degrees C. These results further confirm a role for GABA(B) receptors in the hypothermic and sedative effects of GHB and show an interaction between GHB and MDMA, and GHB and METH, that may be relevant to the experience of recreational users who mix these drugs.

Poly-Drug Use among Ecstasy Users: Separate, Synergistic, and Indiscriminate Patterns

The main objective of this paper is to explore poly-drug use among young adult ecstasy users. This phenomenon of using multiple substances within a specific time period is multi-faceted. In this paper, we focus on the various patterns of poly-drug use and the reasons for combining multiple drugs among ecstasy users. Using a mixed-methods design, we conducted interviews with young adults who used ecstasy and other licit and illicit drugs in the past 90 days. Based on the qualitative analyses, we define three distinct types of poly-drug experiences: separate, synergistic, and indiscriminate use. While separate and synergistic poly-drug use tended to be intentional, indiscriminate poly-drug use often was unintentional. These findings show the importance of recognizing poly-drug use as a common phenomenon. The findings presented here suggest areas for further research aimed at identifying risk and protective behaviors and risk reduction strategies.

Poly-club-drug use among gay and bisexual men: a longitudinal analysis

OBJECTIVE

We sought to delineate patterns of poly-club-drug use among gay and bisexual men. Data were drawn from a large-scale 12-month longitudinal investigation of club drug use and sexual behavior among 450 racially, ethnically, and geographically diverse sample of gay and bisexual men in New York City.

METHODS

Using community-based sampling, we recruited the sample from numerous venues and assessed the self-reported use of five drugs and their relation to one another: cocaine, ecstasy, GHB, ketamine, and methamphetamine. Multivariate hierarchical linear modeling (HLM) was utilized to examine associations of usage over the 12-month data collection period.

RESULTS

Use of the five club drugs was highly related as noted by both parametric and non-parametric analyses of the cross-sectional data. Patterns of use over time also indicated significant longitudinal associations. Specifically, the use of methamphetamine over time was related to both the use of ecstasy and GHB.

CONCLUSIONS

The analyses suggest that usage patterns of individual club drugs such as methamphetamine, ecstasy, and GHB among gay and bisexual men are highly related across time. These findings hold implications for the treatment approaches that are utilized to address substance abuse in this segment of the population, and suggest that practitioners focus on the totality of the substance abuse behaviors and not necessarily individual drugs which are administered.